IJCS | Volume 33, Nº2, March / April 2020

115 Table 3 - Absolute frequency and percentage of each type of medication used for PsA Medication N % Metotrexate 26 57.78 Leflunomide 10 22.22 Adalimumab 08 17.78 Infliximab 07 15.56 Corticoid 03 6.67 Ustekinumab 02 4.44 Etanercept 02 4.44 Naproxen 01 2.22 None 04 8.89 Campos et al. Psoriatic arthritis and cardiovascular risk Int J Cardiovasc Sci. 2020; 33(2):112-118 Original Article waist greater than or equal to 90 cm. 27 Patients who presented at least one of the following were considered dyslipidemic: LDL-C > 130 mg/dL or triglycerides > 150 mg/dl, values adopted by the 2017 BrazilianDyslipidemia and Atherosclerosis Prevention Guideline. 26 Individuals with altered serum CRP and ESR levels presented, respectively, higher levels of LDL-C (p = 0.02) and total cholesterol (p = 0.04). There was no significant difference between serum levels of CRP or ESR according to the different categories of CVR — low, intermediate or high risk. Participants in this study had a median CVR of 13.70% (IQR 5.6-25.3). Patients at high risk for cardiovascular outcomes in the next 10 years accounted for 53% of the sample, 29%had intermediate risk and 18%were low risk. Psoriatic arthritis medications used by the participants in this research data collection period are listed in Table 3. No association was found between the medication used and the calculated CVR compared by Fisher’s exact test. Analyzing the presence of CVR factors and the type of medication used, it was evidenced that patients using leflunomide had significantly higher BMI (t = 2.41, p = 0.03) Discussion This study was performed to quantify risk factors and to assess the CVR of PsA patients followed at a tertiary referral hospital in northeasternBrazil. Corroboratingwith the high CVR found in the sample, in 2013, a systematic review evidenced increased risk of AMI, cardiovascular mortality and stroke in patients with aggressive psoriasis — those who, by definition, require hospital admission or systemic therapy which includes carriers of PsA. Other manifestations of atherosclerotic disease also have increased frequency in patients with psoriasis, such as stroke and peripheral arterial disease. 27 Although notorious, the high occurrence of CVR factors, as well as the risk estimated by GCRS 25 in patients with PsA, do not provide enough evidence to use a multiplier factor for the usual scores, as in rheumatoid arthritis, for example, in which the calculated risk is multiplied by 1.5. 28 Prevalence of hypertension, obesity, hyperlipidemia, type 2 diabetes and the occurrence of at least one cardiovascular event were 37.1%, 30%, 20.7%, 12% and 8.2%, respectively, resulting in a 4.9% increase in the risk of cardiovascular disease, 17.5% in hypertension, 6.2% in hyperlipidemia, 5.3% in type 2 diabetes and 3.5% in obesity compared with patients with psoriasis without arthritis. 29 A 2013 systematic review found a higher prevalence of hypertension in psoriasis patients than in the control group. 30 The same occurred with diabetes in another systematic review of the same year. 31 A population study from the UK found an increased smoking frequency, and all previously mentioned risk factors in psoriasis patients compared to the control group. 32 The sample of this study also revealed a high occurrence of the main predictors of CVR, especially dyslipidemia. The prevalence of hyperlipidemia found in the Canadian study is considerably lower, which may be justified by the non-contribution of low HDL-C patients in the Canadian research statistics, in addition to the current cut-off points being more stringent. Similar to this study, in which the majority of individuals was diagnosed with psoriasis before articular manifestations, skin disease precedes arthritis in approximately 75% of the cases, is simultaneous in 10% of the diagnoses and occurs afterwards in 15%. 33 Studies reveal a large range of variation in the incidence of each type of joint involvement: 15%–78% of the polyarticular form, 16%–70% of asymmetric oligoarthritis, 1%–17% of the form affecting the distal interphalangeal, 2%–16% of the mutilating form and 2%–27% of spondylitis. The overlap between the several subgroups of PsA is frequent and the joint involvement can change, so that patients starting symptomatology with asymmetric oligoarthritis can develop symmetrical polyarthritis over time, for example. Thus, the current trend is to classify PsA in threemain clinical presentations: polyarticular, oligoarticular and axial; it is estimated that